Equity in health, climate and the environment
Two recent publications assess environmental inequalities and health in Europe and the United Kingdom:
Closing the gap in a generation, the final report of the Commission on Social Determinants of Health chaired by Sir Michael Marmot, and Fair society, healthy lives. Strategic review of health inequalities in England post-2010 (the Marmot review) (19,20). According to the latter, life expectancy in England and Wales had increased in 1972–
2005, but continued to be lower for unskilled than skilled workers. Data on the impact of the social gradient in England showed that, for each year, if everyone had the mortality of those with a university education, 202 000 people aged 30 years or more would not die prematurely, thereby gaining 2.5 million years of life.
A conceptual framework to reduce health inequities and improve health and well-being for all should rest on the creation of an enabling society that maximizes individual and community potential and ensures that social justice, health and sustainability are at the heart of policies. To do this, three key actions are recommended.
• Policies and interventions that both reduce health inequalities and mitigate climate change should be prioritized.
• Planning, transport, housing, environmental and health policies should be integrated.
• Locally developed and evidence-based community regeneration programmes should be supported, especially those that remove barriers to community participation and action and that emphasize a reduction in social isolation.
The challenges of equity in health, the steps made towards it and its relationship with climate and the environment can be seen from four angles: equity; gender; climate, environment and health; and the social determinants of health inequalities.The struggle against poverty demands moral, political and social development. Human health is an all-purpose goal and an essential requirement for individual freedom: where equity in health exists, everyone benefits. The WHO Constitution (21) states: “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”. Unfortunately, this definition did not take account of gender, and gender differences in health risks due to environmental exposures persist. Progress towards gender equity is being made, but is unequal.
The situation of the interrelated areas of climate, environment and health is increasingly disquieting, jeopardizing the quality of natural and vital resources and endangering human existence. Development based on ecological and social ethics therefore needs to be promoted.
Policies linked to energy, agriculture and the exploitation of the earth must not disregard health and social analyses that take account of underprivileged populations. Evidence of gains in health conditions and policies is extensive in the EU, where most countries experience the advantages of a social model of health. The past
few years have seen an increased commitment to direct tackling of the social determinants of health and the resulting inequalities. The promotion of health in all policies contributes to population-wide risk prevention, with the most visible effects among underprivileged populations.
Despite these advances, fairness in the health sector must be further promoted to prevent the growth of inequities. Further, several EU resolutions surprisingly couch some exhortations to health in economic terms.
People’s health has its own intrinsic value, beyond its importance to the economy.
Some challenging inequalities
A panel of country representatives provided examples.
In Germany, data support the finding that social status affects health and longevity. The financial crisis is exacerbating social inequalities in risk, especially among children and elderly people. Though limited data are available, these effects need analysis. Minority and migrant populations are also at increased risk. An improvement in primary health care and public health is needed, with a focus on nutrition and general public awareness of health. Germany is working to identify and reduce these environmental injustices and plans to foster greater cooperation and focus on this subject.
In Malta, the increasing numbers of illegal migrants coming from sub-Saharan and northern Africa over the last decade are a cause for concern. On their boat journey to Malta, these people suffer many health risks, including exposure to the weather, overcrowding and even drowning, as well as dehydration, minor burns, scabies and respiratory and gastrointestinal illnesses. After arrival, the migrant population suffers the additional threats of exposure to local pathogens, occupational health and safety problems and sexually transmitted infections, along with the risk of mental ill health due to feelings of isolation, and the traumas faced in their countries of origin or on the journey. In Malta, migrants also concentrate in particular areas, increasing the population density and thus the pressure on the local infrastructure, particularly sewage and waste.
The populations of Malta and the European Region as a whole are entitled to the same environmental conditions and health care, and migrant populations should be a particular focus owing to the risks they face and their generally poorer living conditions. As climate change increasingly threatens Africa, the likelihood of climate refugees rises, with subsequent effects on Malta, particularly the availability of food and water. Malta is seeking comprehensive solutions and making increased efforts to return illegal migrants to their countries of origin, while supporting measures to encourage legal migration.
The Russian Federation supports the need to strengthen the systematic monitoring of the health and environmental situation and to use these data to tailor specific programmes to address them. The exposure of pregnant women to chemicals, at work or in the general environment, is of great concern in the country, due to the possible effects of these exposures on the fetuses. In addition, decreasing chemical exposure during the first year of life is very important to prevent adverse effects on children’s development and health. WHO has a clear role to assist here, with its enormous capacity to disseminate evidence and strengthen health professionals’
capacity.
Chemical safety is also a concern in Slovenia, as people in all countries have the right to live and work in safe environments. Inequalities both within and between countries therefore make it essential for all countries in the European Region to cooperate. Chemicals and chemical safety are key areas where inequality is clearly evident, yet the lack of reliable data and biomonitoring related to health and the environment hinders progress. The legacy of obsolete pesticides, along with chemical contamination from industrial activities, is an additional burden. Slovenia has developed a strategy to strengthen the engagement of the health sector in SAICM and is focusing on improving the management of obsolete pesticides and other chemicals, a topic for discussion at the Sixty-third World Health Assembly and in the EU. The health sector needs to engage to a greater degree with the SAICM initiative, as this sector deals with the consequences of chemicals management.
In 2010, Slovenia is hosting the first meeting of a working group to prepare a strategy for strengthening the health sector’s engagement in chemical management. Joint action of the health and other sectors, along with closer cooperation between Member States and international organizations, can reduce the differences between countries, thus protecting the most vulnerable populations and ensuring a safer environment today and for future generations.
Several participants contributed to the discussion, agreeing that environmental policies need to focus more on population health. Belgium supports the use of norms and standards, but promotes the need for criteria for access to environmental health services and the need for locally based policies and pledges in which the health sector and environment sector work together. To support this cross-sectoral approach, Belgium plans to promote the deeper incorporation of social determinants of health in environmental health policy. In Portugal, health equity is a main component of the national health plan for 2011–2016, which supports citizen empowerment to stop social exclusion and promotes early access to daycare, particularly among migrants.
To support the initiatives on socioeconomic and gender inequities, areas where health policy should tackle health inequity include education, health and environment, and the inclusion of health in all policies. Other areas in which countries can learn from each other include the development of standards and preventive programmes.
WHO has an important role in bringing countries together and identifying what areas would benefit from such convergence. Finally, it is important to remember that a growing economy is not always related to improving health, and some efforts to maintain economic strengths harm the health of poor communities.
In summary, the following issues are key.
• Although intersectoral collaboration is difficult and challenging, it is feasible and a key component in the inclusion of health in all policies, which WHO will continue to support. Countries need to share their experiences, however; for example, Portugal has actively pursued the intersectoral and health-in-all-policies approaches, with resulting improvements in life expectancy and the health of the population.
• The economic crisis can be viewed as a new opportunity to adjust priorities to invest more in health promotion and disease prevention, and to include environmental health in the broader concept of public health.
• Action on the social determinants of health needs to be promoted and this requires leadership and information, which the WHO Regional Office for Europe can provide.